Dr. Michael Kelleher has 30 years of experience as a primary care physician and medical director for large group practices, responsible for patient safety and medical quality improvement. His blog highlights hypothetical patient stories based on
...

Dr. Michael Kelleher has 30 years of experience as a primary care physician and medical director for large group practices, responsible for patient safety and medical quality improvement. His blog highlights hypothetical patient stories based on common medical mishaps, to help patients learn how to avoid these unfortunate events by becoming more actively engaged in their own medical care.

My first blog on this topic discussed the hazards of progression from prescription painkillers to street drugs. However, many opioid related deaths do not involve street drugs, but rather are caused by overuse of prescription opioids, often in combination with alcohol or other medications.

Three recent published studies have documented that the risk of death from opioid overdose increases by more than 300% for those patients using more than the equivalent of 100 mg of morphine daily. This translates to about 65 mg of oxycodone per day. Deaths can occur in patients who escalate their dose without physician authorization, or when sleeping meds or alcohol are added. In some cases medical conditions can also develop which greatly increase the risk.

Consider the following scenario involving a common medical condition:

“Mr. J is a 48-year-old carpenter who has continued to gain weight, now at 290 pounds, translating to morbid obesity for his height 5’10”. He has chronic back pain as well with escalating doses of oxycodone, most recently up 160 mg per day.

His wife notes that he snores heavily with daytime sleepiness so his physician schedules him for an overnight sleep test to look for obstructive sleep apnea (OSA). In the overnight sleep lab, monitors show that the patient has “central apnea” with dangerously low oxygen levels due to long episodes with no breathing efforts. During one of those spells the patient’s heart stops requiring urgent CPR which is fortunately successful. A similar episode at home would likely have been fatal…”

Take-home points include the following:

For non-cancer patients managed by their PCPs the dosing of chronic opioids should be limited to the equivalent of 120 mg of morphine per day when possible. (see dose equivalency link at the end of this blog.)

For patients who require higher doses the US Center for Disease Control (CDC) recommends that the care be guided by a pain specialist, who may also suggest safer approaches for pain control

Obese patients with signs of sleep apnea (snoring, nighttime gasping, daytime sleepiness) are at high risk for opioid related complications as described in the vignette above. Their pain symptoms should be treated very cautiously with relatively low dose opioids, pending evaluation by a sleep specialist. Patients with a confirmed diagnosis of sleep apnea who are using “CPAP” breathing devices in bed are still at high risk with opioids, because they often forget or refuse to use their CPAP device.